Disease Surveillance Report

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					GOVERNMENT OF SOUTHERN SUDAN
     MINISTRY OF HEALTH




    Southern Sudan Integrated
     Disease Surveillance and
   Response Assessment Report



              2007

                     .	   ,-.   -
 Southern Sudan Integrated Disease
Surveillance and Response Assessment
                Report
                        Acknowledgements
This report has been developed with the technical assistance received
from Centre for Disease Control (CDC), in collaboration with World
Health Organisation (WHO), United NATIONS Development Program
(UNDP) and the Ministry of Health (MOH), Government of Southern
Sudan (GOSS), under the leadership of the Directorate of Preventive
Medicine and technical guidance of the Director General, Dr. John
Rumunu.

Therefore, on behalf of the Ministry of Health, Government of Southern
Sudan, I would like to take this opportunity to thank all individuals,
International and UN agencies that contributed to the development of
this draft document.

In particular, the Ministry would like to acknowledge and thank Dr.
Senait Kebede, the Consultant recruited by CDC for her technical
guidance and input that was important in the creation of this
document and Dr. Mugo Muita for the great support.

Many thanks go to all WHO staff and UNDP for their active
participation and technical assistance. Profound gratitude is also due
to Dr. Nathan Atem, Makoy Samuel, Dr. Gregory Wani, Dr. Paul Tingwa
and Dr. Olivia Lomoro for their constructive technical contribution in
the creation of this report. I also acknowledge the technical input from
the Master Students- Field Epidemiology & Laboratory Management
Training Programme. It is the hope of the Ministry that this document
serves as a guide to Integrated Disease Surveillance & Response (IDSR)
programmes in Southern Sudan.


     41rigi

           Yak Kok
Under cretary
Ministry of Health-GOSS




              Southern Sudan Integrated Disease Surveillance & Response
                                Acronyms


AFP	     Acute Flaccid Paralysis
AFRO	    African Regional Office
AIDS	    Acquired Immune Deficiency Syndrome
CDC	     Centers for Disease Control and Prevention
CHW	     Community Health Worker
DFID	    Department for International Development
EMRO	    Eastern Mediterranean Regional Office
FELTP	   Field Epidemiology & Laboratory Management Training Program
GOS	     Government of Sudan
GOSS	    Government of Southern Sudan
HIV	     Human Immunodeficiency Virus
HQ	      World Health Organization Headquarters
IDSR	    Integrated Disease Surveillance & Response
ICEMRI	  Kenya Medical Research Institute
MOH	     Ministry of Health
NGO	     Non-Governmental Organization
OLS	     Operation Lifeline Sudan
PoA	     Plan of Action
WHORO	   World Health Organization Regional Office
SPLA	    Sudan People Liberation Army
SPLM	    Sudanese People's Liberation Movement
TB	      Tuberculosis
UN	      United Nations
UNAIDS	  United Nations Program on HIV/AIDS
UNDP	    United Nations Development Program
UNICEF	  United Nations Children's Fund
USAID	   United States Agency for International Development
WHO	     World Health Organization
WHO/AFRO World Health Organization Regional Office for Africa




                                         iv
              Southern Sudan Integrated Disease Surueitlance do Response
                                                 Introduction
A well functioning disease surveillance system is critical to the health
system in providing evidence-based information for planning,
implementation, monitoring and evaluation of public health
intervention programmes In most developing countries, surveillance
systems are often weak or have developed in an uneven fashion, with
various surveillance activities funded and managed by different control
programmes or organizations resulting in duplication of efforts and
inefficient use of resources and systems. Considering the need for a
synergistic and coordinated method in disease surveillance and to
strengthen its role in control of communicable diseases, the World
Health Organization, African Regional Office (WHO/AFRO), developed a
strategy that is promoting an integrated approach 1.
Since its adoption in 1998, the strategy on Integrated Disease
Surveillance (IDS) has been implemented with encouraging success in
many countries in the African Region. The IDS strategy calls for a
coordinated approach to data collection, analyses, interpretation, use,
and dissemination of surveillance information for decision making and
implementation of public health interventions with the goal to control
and prevent communicable diseases. Strengthening national disease
surveillance and response systems using the integrated approach
involves:
           Intensifying training (in- and pre-service) targeting in particular
           the district health teams
           Establishing focal points and mechanisms for co-ordination of
           surveillance activities
           Strengthening data management at central , intermediate, and
           peripheral levels
           Establishing efficient communication networks within the
           country for prompt reporting and
     e. Building laboratory capacity including networking at national
        and regional levels to support surveillance activities.
Through this strategy, integration and synergy of existing surveillance
systems is envisaged as applicable at all levels of the health system,
particularly at the district level.


 . World Health Organization, Regional Office for Africa. Integrated Disease Surveillance Strategy, A Regional strategy for
communicable diseases 199-2003. Harare: World Health Organization Regional Office for Africa, 1999
                                                                 1
                           Southern. Sudan Integrated Disease Surveillance & Response
The Centres for Disease Control and Prevention (CDC) has been
engaged as a technical partner with WHO and ministries of health to
support countries in the process of design, implementation, monitoring
and evaluation of infectious disease surveillance systems using this
strategy.




                                         2
                uthern Sudan Integrated Disease Surveillance & Response
                                             Background

Southern Sudan covers an area of 610,175 km2 , and is bordered by
Kenya, Uganda, Ethiopia, the Democratic Republic of Congo and CAR.
The population is estimated at about 12,000,000 with a rapid
increasing trend due to post conflict returnees. The country had been
engaged in one of the longest civil wars in Africa with devastating
outcome of massive displacement, depletion of assets, and limited
access to social services and arrest of development in a country which
was already one of the most underdeveloped in the world. According to
the Joint Assessment Mission (JAM) it is estimated that 90% of the
population are living on less than $1 a day income. 2 The civil war was
brought to an end on January 9, 2005, with the signing of the
Comprehensive Peace Agreement (CPA) between the Sudanese
Government and the Sudanese People's Liberation Army/Movement
(SPLM).3




Since the peace agreement, the Government of Southern Sudan has
embarked on addressing the challenges of establishment and re-
construction of the much needed social services including health
services as one of the priority areas. Data from the Sudan Household
Health Survey (2006) indicates infant Mortality rate as 102/1000 live

2 Joint Assessment Mission, South Sudan , MARCH 18, 2005
 Government of National Unity and Government of Southern Sudan , Framework for Sustained Peace, Development and
Poverty Eradication Progress Monitoring Note, February


                        Southern Sudan Integrated Disease Surveillance & Response
births, under-five mortality rate as 135/100 live births and maternal
mortality rate as 2037/100,000 live births, the highest in the world.
Communicable diseases remain a major concern in Southern Sudan.
The main causes of morbidity and mortality are infectious and parasitic
diseases including tuberculosis (TB), Diarrhea, Malaria, Measles and
Acute Respiratory Infections (ARI). Southern Sudan shares the largest
(80%) burden of the total guinea-worm cases world wide. Other
epidemic diseases like Sleeping Sickness and Leishmaniasis are
endemic in certain parts of the country while the prevalence of
HIV/AIDS was found to be low. However there is an observation of an
increasing trend of HIV/AIDS in some parts of the country. Except for
the excellent progress in the eradication of Poliomyelitis, the coverage of
the Expanded Program of Immunization (EPI) has remained low for
many years with variation between the different states4.
In recognition of the urgent need to build surveillance functions for the
control of communicable diseases, the Ministry of Health (MOH) made a
decision to adopt and implement the Integrated Disease Surveillance
and Response (IDSR) approach in Southern Sudan. Initial activities
included sensitization of MOH staff and partners on IDSR and
establishment of IDSR. In order to accelerate the implementation
process of IDSR, the MOH requested CDC for technical assistance to
assist in the assessment of the national communicable disease
surveillance and development of the Plan of Action (PoA) for Southern
Sudan.




4 WHO Consolidated Appeal 2006 based on the UN work plan 2006:
htto://www.whoint/haddonorinfo/Sudan Workolan Nov05.odf

                                                          4
                       Southern Sudan Integrated Disease Surveillance & Response
           Objectives and Expected Outputs

3.1 Objectives
  To conduct assessment of the status of existing communicable
  disease surveillance system and determine the strengths,
  weaknesses and opportunities for strengthening surveillance in
  South Sudan

  To develop consensus on recommendations and priority activities for
  implementation of IDSR

c. To develop a Plan-of-Action (PoA) with goals and process-type
   activities objectives, time-lines, and a preliminary budget.


3.2 Expected outputs
  Findings and recommendations of the IDS assessment reviewed

  Consensus reached on recommendations and priority activities

c. A one year national plan of action with goals, objectives and
   activities prepared.




                                     5
                         Integrated Disease Surveillance & Response
                                              Methods

Under the leadership of the Director General, Preventive Health
Services and in collaboration with WHO, a desk reviews team was
established to facilitate the process of assessment and documentation
by the CDC consultant. (Annex 1) The WHO-AFRO generic assessment
protocol was adapted to suit the specific situation of South Sudan.5
Relevant documents were reviewed and individual interview and group
discussions were held as appropriate. (Annex 2). The findings of the
review were initially discussed at the desk review team meeting and
later presented to the Consultative Group for Health and Nutrition
(CGHN) representing programs at Ministry of Health (MOH), WHO,
Global Fund (GF), UNICEF and other partners. Following the
discussions and consensus, recommendations were developed and
major priority action areas were identified for IDSR implementation in
the country. During the planning workshop, the detailed activities,
objectives, timelines and resources were identified and a plan of action
(POA) developed for the year 2007-08 implementation of IDSR in
Southern Sudan (Annex 3 & 4).




5World Health Organization, Regional Office for Africa. Assessment Protocol for National Communicable Disease
Surveillance Systems and Epidemic Preparedness and Response. February 2000

                                                        6
                       Southern Sudan Integrated Disease Surveillance & Response
                                                                                                            y.	      1
                                                                                                                  1 , 	   ,   41,1 1	   h,
                    Scope of the Assessment

In order to determine the strengths and weaknesses of the existing
communicable diseases surveillance systems in the country, the
assessment covered the main and supportive functions of
communicable disease surveillance with a focus on the following main
elements and areas:

5.1 Elements Assessed

5.1.1 Structure

At central, State, County, Payam and peripheral levels, the existence of
surveillance units or focal points was checked. The representation of
surveillance units or focal points was assessed in comparison to the
overall organizational structure of the particular level.

5.1.2 Process

The following activities in the surveillance process were assessed: case
detection, registration, case confirmation, data analysis and reporting,
feed back, supervision, out break investigation, epidemic preparedness
and response at all levels of the health system.

5.1.3 Output

The assessment examined out puts from the different surveillance
systems at different levels including the presence of weekly, monthly,
quarterly as well as annual reports/plans. Analysis in terms of person,
time and place were also checked.


5.2 Areas Assessed

5.2.1 Priority diseases
Based on the epidemiologic profile of communicable diseases in
Southern Sudan the working group recommended 24 diseases as
priority for IDSR. Thus, this assessment considered the 24 diseases
selected for surveillance, as shown in the table overleaf.


                                           7
                Southern Sudan Integrated Disease Surveillance & Response
Table 1: Priority diseases for IDSR

      Cholera                                      HIV/AIDS
      Bloody diarrhoea                             STIs
      Measles                                      Malaria
      Yellow fever                                 Trypanosomiaisis
      Meningococcal meningitis                     TB
      Viral haemorrhagic fevers                    Onchocerciasis
      Guinea worm                                  Rabies
      AFP                                          Lymphatic Filariasis
      Neonatal tetanus (NNT)                       Kala Azar
      Leprosy                                      Schistosomiasis
      Diarrhoea in under 5 yr                      Acute jaundice syndrome
      Acute respiratory illness                    Avian Influenza (AI)
      (ARI) Under 5 yr




5.2.2 Capacity
In assessing capacity, the review looked into availability and number of
   trained human resources for communicable disease surveillance at
   each level, the type and number of training conducted. In addition,
  availability of budget for surveillance and epidemic preparedness and
response (EPR) was checked. Other elements considered were material
     resources for surveillance including communication equipment,
 transport facility and logistics, emergency stocks of drugs and medical
     supplies for epidemics, data management instruments and IEC
                                  materials

5.2.3. Integration
 Various data collection, analysis and reporting formats were reviewed
      in order to identify possible areas of integration/synergism
5.2.4. Laboratories
One major area of assessment was laboratory function at central, state,
  county and Payam level where present. The structure, capacity and
linkage of laboratory services to the surveillance system were assessed.
                                    8
              Southern (Ian Integrated Disease Surveillance & Response
                                                                             I
   The contribution and role of laboratory services in communicable
disease surveillance and epidemic response was also assessed. Various
   activities of laboratory functions including types of tests available,
  collection and transportation of specimens for referral, availability of
reagents, chemicals, equipment and skilled human resources were also
                                  reviewed.




                                         9
              Southern Sudan Integrated Disease Surveillance & Response
                                                   Findings

The following section describes the results of the assessment in
accordance with the elements and areas described above.

6.1 Health Delivery Systems in Southern Sudan
The health system in Southern Sudan has suffered immensely during
the period of the conflict and efforts are ongoing to revive what is left
and establish new ones as appropriate. A statement within the Health
Policy Indicates that the the Government will focus on strengthening
the primary health care system which was introduced in the 1970s but
which has now deteriorated to almost non-existence. This will be
accompanied by intensive control programs for endemic diseases like
Malaria, TB and HIV/AIDS. Regular campaigns to combat other
debilitating diseases like Sleeping Sickness, Kalazar, River Blindness,
Guinea-Worm and Leprosy will also be carried out, focusing on areas
where they are endemic"6.
The long standing war has left Southern Sudan with major destruction
of health facilities requiring massive effort in rebuilding the various
domains of the health systems. Currently, the MOH-GOSS is still in the
process of organization and the various levels of health delivery
packages are yet to be defined. The overall level of health service
coverage is estimated to be approximately 25% and nearly all health
delivery is done through Non Governmental Organizations (NGOs).
There are few functional health facilities and efforts are being made by
the MOH-GOSS to conduct a comprehensive health facility mapping
exercise to provide data that will identify gaps in the health system.
However it is recognized that most of the health facilities are in poor
state of function and need major input in terms of rebuilding
infrastructure, provision of equipments and supplies and staffing with
skilled health workers. In addition, the deplorable state of roads and
scarcity of communication facilities has resulted in limited access to
health facilities at all levels contributing to the low utilization of health
services.




§ The Government policy statement delivered by the president of the Government of Southern Sudan, K E. Lt. Gen. Salva Kiir
Mayardit, at the opening of the Second Session of the Southern Sudan Legislative Assembly, Juba, 10th April 2006.

                                                             10
                         Southern Sudan Integrated Disease Surveillance & Response
Table 2: Southern Sudan Health Service Utilization indicators



 Indicator                                                                                  SHHS
 Fully Immunized Children                                                                    17.03%
 Births attended by trained personnel (percent)                                             6%
 Institutional deliveries by trained health
                                                                                             13.9%
 personnel
 HH availability of ITN                                                                      11.6%
 Use of sanitary means of excreta disposal                                                  6.4%
 Anti malarial treatment                                                                    46.99%


Communicable diseases remain the major causes for morbidity and
mortality at all levels of the health delivery and various epidemics
continue to occur in different parts of the country. Evaluation of the
health systems at different sites in the country identified numerous
challenges 7 ' 12 . Among the constraints observed during the evaluations
are:
Organizational structure
          Challenges within the transition period following the
          comprehensive peace agreement
          Lack of effective coordination with NGOs delivering health
          services
     c. Lack of adequate budget to support social services and health
        systems
Infrastructure
     a. Most health facilities are in serious need of reconstruction and
        renovation while those that are functioning are lacking
        maintenance services

7 Health System Assessment in former Garrison Towns, Report of Missions to Malakal, Renk, Nasir, Benteu and Pibor
Located in the Greater Upper Nile Region of South Sudan, SOH/FMOH GOSS WHO — USAID — UNICEF 18 — 25 September
2005
                                                            11
                        Southern Sudan Integrated Disease Surveillance & Response
     Underdeveloped roads and mine risks

     Power outage and lack of electricity in some areas

     Shortage of clean water supply

     Lack of appropriate waste disposal systems

Human resources

     Lack of skilled manpower in the area of leadership, management,
     finances and health service delivery at various levels

     Lack of motivation due to irregular salary payment, lack of
     training, supervision, and feedback

Supplies

     Lack of appropriate equipment and supplies including
     medications

     Lack of appropriate protective wears and waste disposal systems
     resulting in breach of infection safety protocols




                                         12
              Southern Sudan Integrated Disease Surveillance & Response
6.2 Existing Surveillance Systems in Southern Sudan

6.2.1 Epidemic-prone and vaccine-preventable diseases
Surveillance activities are among the functions that were seriously
disrupted in regards to the health system. Surveillance officers are
available at the different levels. However, the distribution of these
officers is uneven and there is no mechanism for coordination and
structure for data flow between the different levels.
Recognizing the need for strengthening surveillance activity for
prevention and control of communicable diseases, the MOH adopted
the IDSR strategy and organized a Task Force. The IDSR task force has
specific Terms of Reference (TOR) which is currently under revision
(Annex 5). The establishment of the Task Force has facilitated the
process in IDSR with activities including selection of priority disease
and adaptation of case definitions. However synchronization between
the different case definitions (e.g. EWARN) and WHO case definitions
remains to be addressed (Annex 6).
According to the WHO evaluation report, most confirmed outbreaks in
Southern Sudan concerned Measles, Meningitis, Malaria and whooping
cough. The proportion of outbreaks responded to timely (within one
week from reported onset) showed an improvement from 14% in 2000
to 41% in 2004. The response from time of reporting has also improved
from 85% in 2000 to 97% in 20048.
However, due to multiple reporting formats used by the multiple
partners engaged in health care delivery, there is lack of integrated
report for priority diseases. Data is often incomplete and at times
inaccurate. There is no continuity and consistency in supplying
reporting formats, training, supervision and feedback. There is also
poor communication between the different levels contributing to delay
in information flow and thus delay in response to epidemics. The
current structure of the MOH indicates the designation of a staff at the
national level to strengthen integrated surveillance and response
(IDSR).
The WHO has also expanded its support for strengthening surveillance
and response for epidemic-prone and vaccine-preventable through
recruitment of staff. Currently, in addition to AFP/poliomyelitis and
EWARN, programmes for Malaria control, onchocerciasis (ttntrol,
tuberculosis, and HIV/AIDS are being supported. The integration of


 Strengthening surveillance and response for epidemic-prone and vaccine-preventable diseases in selected African and Eastern -
Mediterranean countries WHO/CDS/CSR/LY0/2005.23

                                                             13
                         Southern Sudan integrated Disease Surveillance & Response
EWARN and surveillance activities for AFP/poliomyelitis is taking place
gradually

6.2.1.1 Acute Flaccid Paralysis (AFP) surveillance
The Acute Flaccid Paralysis (AFP) surveillance system began in 1998
and receives support from the WHO Country Office, the WHO Regional
Office of the Eastern Mediterranean (EMRO), UNICEF, several NGOs,
and other partners. The WHO Polio Eradication activity in South Sudan
began in 1998 and is implemented under the umbrella of Operation
Lifeline Sudan (OLS) in collaboration with other NGOs. Operation
Lifeline Sudan coordinates activities between the Government of
Sudan, humanitarian wings of the rebel forces, UN Agencies, and NGOs
while WHO and UNICEF provide technical support and assist the
coordination of logistical and financial support for the program.
Despite many challenges, the program has covered all areas in the
south under SPLM control and also supported activities in Nuba
Mountains and Southern Blue Nile. Active surveillance visits are
conducted by field assistants (FA) in 341 sentinel sites and 1523 other
reporting sites through out Southern Sudan. Case notification and
arrangement for stool specimens are communicated immediately
through radio and email. Stool specimens are frozen and shipped to
Loki from where they are transferred to the Polio Reference Laboratory
at Kenya Medical Research Institute (KEMRI) in Nairobi-Kenya for viral
isolation. Subsequently, isolates requiring Intra-Typic Differentiation
(ITD) are sent to the WHO/AFRO Regional Reference Laboratory in
South Africa.

AFP data are managed by a data manager who receives hard copies of
the AFP initial and detailed case investigation forms from the field and
lab result from KEMRI. In collaboration with the Program Coordinator,
data is cleaned, edited while data entry and analysis is centralized
under the Technical Officer in Nairobi.Zero reports and work plans are
submitted monthly. The Polio Eradication Program in South Sudan is
one of the well developed programs in the region. It is noted that
Southern Sudan achieved the polio certification level surveillance
targets of all indicators in 2002 and has maintained it since then.
However, due to on-going security risk, inaccessibility of some areas,
logistical and infrastructural constrains it is of concern that wild polio
cases could be missed in some regions, particularly in Upper Nile,
Lakes, Baher El-Ghazal and Eastern Equatoria9 . Other challenges for
the program include long interval between case detection and mop up
campaign, high turnover of trained staff, slow response to field needs of

9 AFP Surveillance Review South Sudan September 6 — 16, 2005
                                                14
                    Southern Sudan Integrated Disease Surveillance & Response
operation materials including communication equipments, weak
feedback and incomplete monthly zero reporting from Payams 10 . Since
2003, Measles Surveillance System was integrated into AFP
surveillance.

6.2.2 Surveillance of Guinea worm

The Sudan Guinea Worm Eradication Program (SGWEP) -Southern
Sudan Project is managed by a MOH-GOSS designated Project
Coordinator, who is accountable to the Director of Preventive Health
Services. The Carter Centre, which provides technical, financial and
logistic support for SGWEP, is a collaborating partner, along with
UNICEF, WHO, CDC, and international and local agencies.

   Southern Sudan carries the largest burden (80%) of all the cases of
     Guinea worm in the world. The Program covers most of States in
     Southern Sudan with exception areas in Upper Nile and Eastern
 Equatoria states, due to the vastness of areas to be covered and poor
 road access. The program has a well organized system of surveillance
    including the use of community health workers with documented
success. The Guinea Worm Surveillance covers 7.5 millions people in 9
    States in South Sudan with over 1085 endemic villages and 1115
villages under surveillance from January - December 2005. Some of the
                constraints for the program include: 11 12

          Poor documentation - only 8.2% (454/5565) of all cases
         reported in Southern Sudan had accompanying patient forms
         and dates verifying that the case containment process had been
         followed. Of those with forms, only 5.71% (38/5565) were
         correctly filled and only 61% (194/318) of these were properly
         documented as "Contained".

         Poor supervision - there were virtually no supervisory structures
         in most counties and Payams during 2005. This not only
         hampered the case confirmation aspect of the process, but also
         creates concern regarding reliability of data and timely supply
         and guidance on-the-job training to volunteers.




I° AFP surveillance system evaluation report , South Sudan ,June —August 2006 .Dr. Lucy, FELTP,
JKUAT
I I Evaluation of Guinea Worm Community- based Surveillance, South Sudan, June-August, 2006,
Dr. Mounri Christo Lado, FELTP, JKUAT
12 Technical Report on Guinea Worm eradication activities in South Sudan. Jan-Apr 2006.Makoy Samule Yibi

                                                     15
                      Southern. Sudan Integrated Disease Surveillance & Response
     Surveillance structures too weak to detect cases within 24 hours
     - insufficient numbers of volunteers to ensure that every village
     had 1+ trained volunteer.

     Inefficient logistics- the lack of on-site supervisory, logistics, and
     communications presence largely inhibited re-supply.

  e. Sub-optimal experience with, and understanding of, case
     containment.

  1. Lack of standardized approach to, and understanding, of
     international standards for case containment.

6.2.3 Early Warning and Response Network (EWARN)


Because of the complex nature of the emergency, frequent epidemics
and lack of systems for case identification and appropriate response in
Southern Sudan, United Nations Children's Fund (UNICEF), Operation
Life Line Sudan (OLS) and WHO identified an early warning response
network (EWARN) as a high priority. EWARN implementation was also
part of the joint WHO and CDC team recommendation following the
successful control of the 1998-99 relapsing fever outbreaks and similar
various recommendations prior to the epidemic. The presence of OLS to
negotiate access to humanitarian services and the existence of over 70
health partners provided the opportunity for EWARN.

EWARN is funded from various sources and has wide participation of
health care programs supported by multiple organizations. The
agencies and organizations that participate in EWARN include 24 NGOs
with health programmes, two local counterpart organizations, two
health training schools, the International Committee of the Red Cross
(ICRC) at Lopiding and Norwegian Church Aid (NCA) at Yei, County
Health Departments and WHO. There is high-level awareness of
partners in EWARN with growing collaboration from technical partners
including the Kenya Medical Research Institute (KEMRI) and AMREF.
EWARN is building upon the AFP programme infrastructure and the
AFP/Polio staff.

Weekly surveillance data are received from eight sentinel sites,
including three newly added ones. Updates are provided to all partners
through a monthly update on EWARN issued electronically.

Between 2000- 2006, over 280 rumours of outbreaks were reported and
responded to by EWARN. The diseases investigated include:
                                          16
               Southern Sudan Integrated Disease Surveillance & Response
      Suspected VHF in Yambio-Jan 2001 and Feb 2002
      Nodding Syndrome/disease in Lui-Aug 2001
      Buruli Ulcer in Tambura-July 2002
      Viral Encephalitis in Nuba Mountains-2003
      Yellow Fever in Imotong in May 2003	                -
      Ebola outbreak in Yambio in May-Aug, 2004
      Acute Jaundice Syndrome in Tonj & Wadaga Aug-Sept, 2005.
      Suspected Monkey Pox In Bentiu Jan 2006.
   i. Cholera in Equatorial, Upper Nile & Bhar El Ghazal, Feb, 2006.
      Acute Jaundice Syndrome in Malakal (HEV) , March ,2006
   k. Meningitis in Greater Bahr El Ghazal in March , 2006

Despite the progress made in EWARN, poor communication network for
outbreak reporting, poor data quality, lack of timely analysis and
interpretation at the health facility and limited capacity for response
pose significant constraints. Other challenges include; the coping up
with high turnover of trained personnel, strengthening the weak
logistical support, and making resources available to implement
EWARN.

6.2.4 Epidemic preparedness and response
There is no specific budget line or structure for epidemic preparedness
and response activities at national or lower levels. However due to the
complex emergencies, the country had been using the EWARN system
which responds to epidemics. According to the Policy Statement on
Emergency Preparedness "The Federal Ministry of Health,
Government of South Sudan is committed to develop and
institutionalize a comprehensive health preparedness plan at federal
and local levels and to allocate appropriate resources in order to be able
to respond to natural and man-made emergencies in an effective and
timely manner. This work will be undertaken in close collaboration with
other ministries". In line with this policy, a positive experience is
emerging with the recent epidemic threat with Avian Influenza (AI).




                                          17
               Southern Sudan Integrated Disease Surveillance & Response
6.2.4.1 Avian Influenza


The Avian Influenza Task Force was set up in April, 2006 in Southern
Sudan. It is chaired by the Ministry of Animal Resources and Fisheries
(MARF) with the Ministry of Health (MOH) as co-chair. Membership
includes the Ministry of Animal Resources and Fisheries, Ministry of
Health, Ministry of Information, law enforcement and security arms of
the Government, FAO, WHO, UNICEF, CDC, and NGO partners.

Control efforts are being supported by the Government of Southern
Sudan, the Government of Sudan and their partners. Support to the
control efforts included materials, funding and personnel. Since the
announcement of the isolation of Avian Influenza's virus from chicken
samples collected on August 04, 2006, the Task Force has initiated
many control activities including public awareness campaigns,
intensified surveillance, poultry movement restrictions, and training of
both animal and human health personnel. Essential supplies have also
been stockpiled. The MOH-GOSS has a rapid response team and an
isolation room at the Juba Teaching Hospital.

While the current efforts have mainly been limited to Juba, there are
plans to roll out similar preparedness activities to other parts of
Southern Sudan in the coming months. Plans include de-stocking and
active surveillance.

6.3 Laboratory

Southern Sudan has a central referral laboratory with structures for
coordinating the laboratories at the different levels. However most of
these laboratories have not yet resumed function and activities
including training of laboratory staff have been disrupted during the
conflict. Thus, -laboratory personnel with bench training and little
formal education are operating many of the health services. The Central
Referral Laboratory is non-functional and there is no focal point for
coordinating laboratory services at the central level (MOH). Standard
Operating Procedures (SOP) and minimum laboratory packages for the
different levels are not yet defined. There is no system for internal or
external quality control and quality assurance of laboratories in South
Sudan. The laboratories are poorly equipped and supplied, and
methods are inefficient. Currently, as the national level is planning to
rebuild and restructure, collaboration with partners has continued with
encouraging progress in some areas 13 ;


13 Strengthening surveillance and response for epidemic-prone and vaccine-preventable diseases in selected African and Eastern
Mediterranean countries WHO/CDS/CSR/LYO/2005.23


                                                               18
                          Southern Sudan Integrated Disease Surveillance & Response
         In collaboration with AMREF, Laboratory training materials were
         developed for improving clinical and laboratory skills, enhancing
         reporting and data use, laboratory-based data management,
         collecting, preserving and transporting specimens to the
         reference laboratory, bio-safety measures, and interpreting
         laboratory results.

         Establishment of 4 mobile laboratory kits (AMREF) with the
         capacity to conduct up to 500 different tests in the field and
         media to transport specimens that cannot be tested in the field.
         An additional 11 kits were prepared by the EWARN team from
         the UNFIP budget.

         In collaboration with WHO and KEMRI and AMREF laboratory
         confirmation of suspected outbreaks of Ebola, yellow fever, Kala-
         azar and meningitis.

         On-the-job training of laboratory staff, with particular emphasis
         on methods of sample collection, shipping and safety by staff
         from KEMRI.

6.4 Core Functions of Surveillance

6.3.1	         Case Detection and registration

The IDSR Task Force has adopted the WHO case definitions for most of
the selected priority diseases in South Sudan. However there is a need
to synchronize these case definitions with existing ones and fill the gap
for those diseases not listed on the WHO generic list of priority
diseases. It appears that not all health facilities have Standard Case
Definitions (SCDs) at their levels. There are no standard tools for
registration at the facility level in all parts of Southern Sudan. Thi g is
largely due to the fact; most facilities are run by NGOs/partners who
use independent tools for registration, and reporting. Disease programs
like the Guinea Worm Eradication Program (GWEP) and Acute Flaccid
Paralysis (AFP) have specific data collection tools for those particufar
diseases. The EWARN system also have such tools but these may not
capture all that are required to be contained in the tools for the priority
diseases adapted for southern Sudan.


6.3.2 Case confirmation

In assessing the case confirmation mechanisms, it is recogniZed that
structural systems and standards at different levels may'be different-foi
                                    19
                 Southern. Sudan Integrated Disease Surveillance & Response
different levels of central, state, county and health unit laboratories.
Shortage of human resource, equipment and reagents were the main
reasons mentioned for the limited or weak capacity of these
laboratories at all levels. In addition, the linkage between different
levels of the surveillance system and the laboratory is found to be very
weak or non-existent. Most laboratories lack the capacity to transport
various types of specimens to the next higher level, and there is no
defined referral system for laboratory services. In specific situations
where confirmation is required for suspected outbreak conditions, the
MOH-GOSS and State Ministries of Health (SMOH) utilize the
laboratory services located at KEMRI in Kenya.


6.3.3 Data reporting

Generally, there is lack of consistent system for weekly, monthly,
quarterly and annual reporting for communicable disease surveillance
except for the few programs with established systems. Though
summary forms for weekly, monthly and quarterly reports were
available for review, verification of timeliness and completeness of these
reports was not possible. This is due to lack of monitoring of
completeness and timeliness at all levels except for AFP surveillance.
The assessment also revealed that vertical programs have surveillance
systems and use their own data collection, compilation and reporting
formats. The monitoring and evaluation team at the MOH-GOSS is
currently working on this area and this provides an opportunity for
synchronization of the different forms and tools.


6.3.4 Data analysis

There is very little or no data analysis at health facility level. Line
graphs for major communicable diseases and for epidemic prone
diseases are not evident and description of data in terms of person,
place and time is not available. The main reasons for these limitations
are lack of trained personnel, simplified reporting formats, supervision,
and feedback.


6.3.6 Feedback and supervision

Although supervisions are usually planned at various levels, the
implementation is very limited. Supervisory feedback books and
feedback reports from the supervising body were not available for the
desk review. Among the factors identified for weak supervision and feed
back are: lack of standard checklist, skill, transport, incentive,
                                         20
               Southern Sudan Integrated Disease Surveillance & Response
coordination, low awareness on the importance of supervision, and
motivation. As a result, supervision and feed back are irregular and
ineffective.


6.3.7 Communication and Resources

In general, there is scarcity of electricity, vehicles, telephone, radio, e-
mail, and computer services with Internet connections. The health
facilities particularly at the periphery have no road transport
communications. In addition, shortage of budget, difficult terrain, and
rainy seasons present a significant challenge for communication
between rural facilities and county health facilities. As a result,
reporting is delayed, with late response to epidemics and lack of timely
provision of essential drugs and supplies.


6.3.8 Coordination

The MOH-GOSS has established a structure named Consultative Group
for Health and Nutrition (CGHN) to provide the mechanism by which it
can coordinate activities of development partners including donors, UN
agencies and NGOs. The objective of CGHN is to increase the
effectiveness and efficiency of the health sector in support of the
attainment of South Sudanese health policy goals and strategies. The
IDSR working group is closely linked with CGHN and constantly
updates its members on the progress regarding IDSR activities.

The IDSR Task Force was established with representatives from
programs at the MOH and partners. The working group has introduced
IDSR to CGHN, selected priority diseases and had been instrumental to
the planning and execution of this assessment process. The Terms of
Reference for the IDSR working group have been reviewed pending final
approval (Annex 5).




                                         21
               Southern Sudan Integrated Disease Surveillance & Response
               Conclusions and Recommendations

7.1 Conclusion


From the above findings, it is concluded that apart from the few vertical
progyams, integrated disease surveillance system in South Sudan is not
developed and there is significant gap in both the core and support
activities of communicable disease surveillance at all levels of the
health system. The commitment of the Government, existence of
supporting policies, and the initiative of the Director General,
Preventive Health Services to implement the IDSR strategy is a timely
response to address these challenges and strengthen the effort in
controlling communicable diseases in Southern Sudan. The following
recommendations are forwarded for the implementation and
strengthening of IDSR:


7.2 Recommendations

MOH-GOSS

      Establish focal points for I9SR at. National, State, County and
      Payam levels.
      Establish Epidemic Preparedness and response team at National,
      state, county and Payam levels
      Strengthen IDSR working group through representation of all
      major stake holders including NGOs
      Conduct IDSR orientation meetings for representatives of health
      systems at national and state levels including partners.
      Develop a Human Resource strategy for IDSR implementation
      through organizing workshops for assessment need and planning
      at all levels
      Adapt IDSR guidelines and tools for training on various aspects
      of surveillance at all levels
      Review case definitions, reporting formats & data collection tools
      for all levels
      Establish thresholds for epidemics & allocate resources for
      prompt response


                                        22
               Southern Sudan Integrated Disease Survez ante Response
  i. Strengthen the national central laboratory to improve case
      detection, ensure quality control and quality assurance of
      laboratories at all levels through networking including with
      regional and international laboratories
    Ensure timeliness and completeness of reports through training,
    support supervision and improved communication
 k. Enhance data analysis and use through training of data
    managers and health workers, and providing essential equipment
    and supplies
 1. Promote effective feedback and supervision by maintaining
    regularity of activity, using checklists and written feedback,
    training, review meetings, and publication of Bulletins
    Develop communication capacity and avail essential resources
    through proper planning and shared use of resources (efficiency),
    and provision of critical supplies
    Develop/adapt indicators for monitoring and evaluation of IDSR
    implementation and conduct evaluation at least once by the end
    of one year.
 o. Organize a study tour to gain experience on IDSR from
    implementing countries.


WHO/CDC
    Continue technical assistance
    Support advocacy and mobilization of additional resources




                                       23
             Southern Sudan Integrated Disease Surveillance & Response
                                ANNEXES


Annex 1:	        Agenda
Annex 2:	        List of documents reviewed
Annex 3:	        SWOT analysis table
Annex 4:	        List of participants
Annex 5:	        IDSR Task Force terms of reference
Annex 6:	        Case definitions




                                      24
            Southern Sudan Integrated Disease Surveillance & Response

                                                        , 	   1,
                                     Annex 1
                                      Agenda

       Assessment and plan of Action for IDSR-Southern Sudan
                          19- 27, Oct 2006


Thursday Oct 19, 2006
                         Meeting with Director General, Preventive Health
1.00 Pm
                         Services
2:00 - 3:00 Pm           Lunch
3:00- 4:00 Pm
                         Meeting with WHO team
4:00-5:30 Pm
                         Meeting with FELTP residents
Friday Oct 20, 2006
9:00-11:30               IDSR task force meeting
12:00-1:30
                         Desk review team meeting
1:30-2:00pm              Lunch
2:00-5:00
                         Desk review
Saturday Oct 21, 2006
9:00-13:00               Desk review
13:00-14:00              Lunch
14:00-17:30              Desk review + small group discussion
Sunday Oct 22, 2006
9:00-1:00                Desk review
1:00-2:00
                         Lunch
2:00-5:30
                         Desk review + small group discussion

Monday Oct 23, 2006
8:00- 1:00               Group discussion on assessment findings
                                            25
                 Southern Sudan Integrated Disease Surveillance & Response
1:00-2:00                Lunch
                         Group discussion on assessment findings&
2:00- 3:00
                         recommendations
Tuesday Oct 24, 2006
08:00- 12:00             Group discussion on Plan of action (POA) for IDSR
12:00-13:00
                         Lunch
13:15- 15:30
                         Group discussion on POA
15:30-16:00
                         Coffee break
16:00-17:30              Group discussion and finalization of POA
Wednesday Oct 25, 2006
Meeting with-the health and nutrition consultative group (HNCG)
                     Presentation of finding of the desk review of
09•00-09•30
                     surveillance and response systems
09:30 -10:30         Plenary and recommendation
10:30 -1045              Break
                         Review of the POA for IDSR implementation 2007-
10 •45 - 11•15
                         08
11:15 - 13:00            Plenary
13:00 - 1400             Lunch
15:00 - 17:00            Review of feedback
Thursday, Oct 26, 2006
am and pm                Finalization of interview and draft report
Friday, October, 27, 2007
09:00-10:00	      _      Debriefing MOH/IDSR working group




                                           26
                 Southern Sudan Integrated Disease Surveillance & Response
                             Annex 2

                List of documents reviewed



     World Health Organization, Regional Office for Africa.
     Integrated Disease Surveillance Strategy, A Regional strategy
     for communicable diseases 199-2003. Harare: World Health
     Organization Regional Office for Africa, 1999
     Joint Assessment Mission, Southern Sudan , MARCH 18,
     2005
     Government of National Unity and Government of Southern
     Sudan , Framework for Sustained Peace, Development and
     Poverty Eradication Progress Monitoring Note, February
     Southern Sudan centre for statistics 2003
     WHO Consolidated Appeal 2006 based on the UN work plan
                                   2006
     http: / www.who. int / hac / donorinfo/ Sudan Workplan NovO
                                   5. pdf
      World Health Organization, Regional Office for Africa.
      Assessment Protocol for National Communicable Disease
      Surveillance Systems and Epidemic Preparedness and
      Response. February 2000
7.	   The Government policy statement delivered by the president
      of the Government of Southern Sudan, H.E. Lt. Gen. Salva
      Kiir Mayardit, at the opening of the Second Session of the
      Southern Sudan Legislative Assembly, Juba, 10th April
      2006.
               8. Reports. WWW.MOHGOSS.sd
9.	   Health System Assessment in former Garrison Towns,
      Report of Missions to Malakal, Renk, Nasir, Benteu and
      Pibor Located in the Greater Upper Nile Region of South
      Sudan, SOH/FMOH GOSS WHO - USAID - UNICEF 18 - 25
      September 2005
     10. Bor Town, Jonglei State Rapid Assessment 19 - 22
                    December, 2005, GOSS FMOH +
11.	 Health System Assessment in former Garrison Towns,
      Report of a Mission to Wau, Aweil, Gogrial, Raja, Draft
      October 28th 2005

                                     27
           Southern Sudan Integrated Disease Surveillance & Response
12. Health System Assessment in former Garrison Towns.
   Report of a Mission to Juba Final DraftSOH/FMOH GOSS -
        WHO - USAID - UNICEF 5 - 10 September 2005
  Strengthening surveillance and response for epidemic-prone
  and vaccine-preventable diseases in selected African and
  Eastern	                Mediterranean	             countries
  WHO/CDS/CSR/LY0/2005.23
  AFP Surveillance Review Southern Sudan September 6 - 16,
  2005
  Dr. Mounri Christo Lado, FELTP, JKUAT. Evaluation of
  Guinea Worm Community- based Surveillance, Southern
  Sudan, June-August, 2006,
  Makoy Samule Yibi. Technical Report on Guinea Worm
  eradication activities in Southern Sudan.Jan-Apr 2006.
  Strengthening surveillance and response for epidemic-prone
  and vaccine-preventable diseases in selected African and
  Eastern	                Mediterranean	             countries
  WHO/CDS/CSR/LYO/2005.23
  Dr. Lucy, FELTP,	 JKUAT. AFP surveillance system
  evaluation report , Southern Sudan, June -August 2006




                                28
      Southern Sudan Integrated Disease Surveillance & Response

                     nn	   /
                                  Annex 3

                             SWOT Analysis


               Strengths                                      Weaknesses
•   Government leadership and                      •   Lack of skilled human
    commitment.                                        resources.
•   Multiple partners supporting the               •   Weak Laboratory
    health sector                                      capacity.
•   A lot of experience from other                 •   Weak communication
    countries implementing IDSR                        system and
•   Positive experience from Polio                     infrastructure.
    Eradication, Guinea Worm                       •   Diversity of data collecting
    Eradication and EWARN                              tools.
•   Recognition of the relevance of                •   Lack of regular
    IDSR to South Sudan situation.                     supervision and feedback
                                                       mechanisms.

             Opportunities                                    Threats
•   Early stage of establishing MOH                •   Weak County Health
    structures and systems                             Departments (CHD).
•   Supportive policies                            •   Insecurity
•   International good will tpwards                •   Low health coverage
    southern Sudan.                                    (25%).
•   Comprehensive peace agreement                  •   Rapidly changing
    (CPA)                                              population dynamics




                                        29
              Southern Sudan Integrated Disease Surveillance & Response
                                            Annex 4

         List of Participants in the IDSR Desk Review, 23, Oct, 2006


      Name                 Designation             Telephone #         E-mail
                         Director General
                          for Preventive
      John Rumunu                                                      lohn.rumunuAMOHGOSS.
                         Medicine, MOH,
                                                                       sd
                               GOSS
                             National
      Mackoy
                           Coordinator,          +881264338662         mackovsamAyahoo.co.uk
      Samuel Yibi
                         SSGWEP, GOSS
                        Technical Advisor,
      Robert Azairwe     National Malaria           0477107393         azairwermsh.org
                             Program
                         Resident Advisor,                             mugo.muitaa,vahoo.com
      Mugo Muita
                               CDC                                     mmuitaake.cdc.gov
                          Epidemiologist,
      A R Wurie                                                        arwurieayahoo.co.uk
                               WHO
                        Director Laboratory
      Gregory Wani        Services, MOH,            0912806376         gregorywanavahoo.com
                                CES
                           EWARN Team            +8821633338874        richardlakuAvahoo.com
      Richard Laku
                           Leader, WHO            +254721817579
                         Director General
      Nathan Atem       for External Desk,                             riakatem2003Avahoo.com
                            MOH, GOSS
                             Resident
                                                 +8821621701538        moloionga,vahoo.com
      Mounir Lado         Epidemiologist,
                                                 +254733803039         mounir ladoAvahoo.co.uk
                            MOH, GOSS
      Tekleab
                                UNDP
      Tedamo
      Mickey                   WHO                                     mickeyAbidii.com
                         Director, Research
                                                                       achaberAvahoo.co.uk
      Olivia Lomoro      and Health System       +254-733827105
                                Dev
                                                                       Skebede550vahoo.com
13.   Senait Kebede       Consultant, CDC          +4042963241




                                                 30
                       Southern Sudan Integrated Disease Surveillance & Response
      List of Participants in the IDSR Plan of Action Development, 24,
                                   Oct, 2006

#    Name                   Designation                Telephone #      E-mail
     Paul Tingwa       Director for Integrated         0912887956
                       Control Program, CES
     Mackoy            National Coordinator,          +881264338662     mackovsamO,vahoo.co.uk
     Samuel Yibi          SSGWEP, GOSS
     Robert              Technical Advisor,            0477107393       azairwert&,msh.org
     Azairwe              National Malaria
                              Program
     Mugo Muita        Resident Advisor, CDC                            mugo.muitaavahoo.com
                                                                        mmuita3ike.cdc.gov
     A R Wurie         Epidemiologist, WHO                              arwurieavahoo.co.uk
     Gregory Wani       Director Laboratory                             gregorywanavahoo.com
                        Services, MOH, CES          0912806376
     Richard Laku      EWARN Team Leader,         +8821633338874 richardlaktavahoo.com
                               WHO                 +254721817579
     Mounir Lado              Resident            +8821621701538 moloiontavahoo.com
                       Epidemiologist, MOH,       +254733803039 mounir ladoavahoo.co.uk
                               GOSS
9.   Senait Kebede       Consultant, CDC              +4042963241       Skebede550,vahoo.com




                                                 31
                     Southern Sudan Integrated Disease Surveillance & Response
                                    Annex 5
   Ministry of Health, Government of Southern Sudan
          Integrated Diseases Surveillance and Response
                  (Draft 2.0, Tuesday, August 22, 2006)



Working Group Terms of Reference
The Integrated Diseases Surveillance Working Group (IDSWG) is formed
under the broader mandate of the Health and Nutrition Consultative
Group (HNCG) of the Ministry of Health, Government of South Sudan
(MOH, GOSS)
The IDSWG will work under the direction of the Director General,
Preventive Medicine, MOH, GOSS.
The broad purpose of the IDSWG is to provide Technical Assistance
(TA) to the MOH in developing an integrated diseases surveillance
system for South Sudan.
In achieving the broad purpose, the terms of reference (ToR) for the TA
IDSWG will be as follows:
      Develop a strategic plan and plan of action with realistic timeline
      and milestones to guide the work of the IDSWG
      Conduct a review of the existing surveillance systems in South
      Sudan
      Review and recommend resources required (funds, personnel,
      materials and supplies, and commitment) for an integrated
      diseases surveillance system for South Sudan at all levels;
      community, Boma, Payam, county, state and national
      Identify priority infectious diseases for surveillance.
      Recommend a structure(s) for an integrated diseases surveillance
      taking into consideration the different levels and existing systems
      Develop and recommend a roll-out plan for the wider
      implementation of an integrated diseases surveillance in
      Southern Sudan



                                          32
               Southern Sudan Integrated Disease Surveillance & Response
  Recommend and develop tools for the specific training needs to
  build capacity at community, Boma, Payam, county, state and
  national levels
  Review and recommend mechanisms for developing and
  strengthening links between community, Boma, Payam, county,
  state and national levels
  Develop a monitoring and evaluation plan for the integrated
  diseases surveillance system and recommend mechanisms for its
  implementation
  Recommend on-going training for data analysis and usage at the
  different levels
  Recommend ways to assist in the establishment and support of
  national IDS coordination and implementation mechanisms.
  Provide technical assistance in developing appropriate
  information dissemination mechanisms within and outside of the
  MOH including feedback.
  Provide technical assistance in adaptation of IDSR technical
  guidelines including development and use of formats and
  guidelines for IDSR implementation.


Composition of the IDS WG
  The IDS WG membership includes
  MOH
  UN agencies
  Bilateral/Multilateral donor agencies
  NGOs
  Other agencies/institutions/organizations that may be co-opted
  ad-hoc or permanently to fill identified gaps




                                     33
           Southern Sudan Integrated Disease Surveillance & Response
                                      Annex 6

                                Cased Definitions


      Case Definitions of Selected Epidemic-Prone Diseases
  Adapted by WHO/Sudan-southern Sudan; for Use at Health Facilities

                   Drafted June 2000, Updated July 2001

Acute Flaccid Paralysis (AFP): Any case of weakness or flooping (paralysis) of
sudden onset not due to injury, in a child less than 15 years of age or any
case of any age if a clinician suspects polio. Report even if a single case.
Acute (Viral) Haemorrhagic Fever Syndrome: Illness with onset of fever and
at least one of the following signs of bleeding: bloody diarrhoea (melena),
bleeding from gums, bleeding into skin (purpura), bleeding into eyes and
blood in urine. Suspect for Ebola. Report even if a single case.
Acute Bloody Diarrhoea (Dysentery; Shigellosis): Three or more loose stools
in 24 hours with visible blood in the stool.
Acute Watery Diarrhoea (Cholera): Sudden onset of severe, profuse (much
amount) and frequent (more than 3 times a day) watery and also rice-color
diarrhoea,with sunken eyes with/without vomiting among five years of age or
more patient. Report even if you suspect a single cholera case.
Malaria: Fever with chills, shivering, sweats, headache, joint pain, nausea
and vomiting. Suspect an outbreak if unusually high number of cases/deaths
observed.
Measles: Fever and generalized body rash (non- vesicular- no fluid inside),
and at least one of the following: cough, runny nose(discharging fluids), or red
eyes (conjunctivitis).
Meningococcal Meningitis: Sudden onset of fever ( >38.5 0 c rectal OR > 380 c
axillary) and one of the following signs: stiff neck, altered consciousness or
purpural skin rash.
Suspect meningitis in a patient under one year of age: fever with bulging
fontanel.
Suspect an outbreak: 15 cases per 100,000 population per week (if
population estimate is known). Or; Doubling of cases from one week to the
next for a period of three weeks.
Relapsing Fever: Any person with febrile illness with alternative afebrile
period in between; with or without headache, petechial skin and mucous
membrane rashes.
Yellow Fever: Acute onset of fever, followed by jaundice (e.g. yellowish
discoloration of the eyes) within two weeks of onset of the first symptoms.
When you suspect an outbreak, investigate and also report to your NGO, authorities and
WHO


                                             34
                  Southern Sudan integra ted Disease Surveillance & Response
       Case Definitions of Selected Epidemic-Prone Diseases
              Adapted by WHO/Sudan-southern Sudan;
    To Assist Communities' Reporting (Use at Community Level)
                   Drafted June 2000, Updated July 2001


  Acute Flaccid Paralysis (AFP): Any young person who was earlier
healthy and with sudden difficulty to move and use legs and arms with
                     no history of known injury.

 Acute (Viral) Haemorrhagic Fever Syndrome: Any person with fever
  and bleeding or a sudden death from high body heat .."fever" „and
bleeding from the nose or mouth, and/or a large amount of blood stool,
                             red urine.

  Acute Bloody Diarrhoea (Dysentery): A person with frequent loose
   stool (Diarrhoea) who has or tells that s/he has blood in the stool.

  Acute Watery Diarrhoe (Cholera): Any person aged 5 years or more
            with very much amount watery and frequent stool.

   Malaria: High body heat ... followed with "feeling of coldness" and
                                    shivering.

Measles: A child with heat, widespread body rash, red eyes, nasal fluid
                                   or cough .

     Meningitis: A person with high body heat ..and neck stiffness.

    Relapsing Fever: A person with high body heat...then no fever...
                               followed by fever.

   Yellow Fever: A person with high body heat, yellow eyes or yellow
                                      urine.




If you suspect any of the above diseases, inform   a   health worker or an NGO in your
area




                                        35
                Southern Sudan Integr d Disease Some nce & Response
)
                   Part II




                         36
Southern Sudan Integrated Disease Sun lance & Response
                              Introduction
As a follow up from the IDSR assessment fmdings, the Ministry of
Health, Government of Southern Sudan in collaboration with CDC,
WHO, and representatives of other partners, held a planning
workshop on 24 October, 2006.


     Justifications for Implementation of IDSR
As described in the assessment section, communicable diseases
continue to be the major threat to the health development in South
Sudan. The complex and recurrent epidemics coupled with
devastation from the conflict is claiming thousands of lives every year.
The economic and development impact of these epidemics is evident
through analysis of various indicators including health. Despite efforts
to contain and control communicable diseases, the activities for
control and response are met with various challenges. Among these
are lack of skilled human resources, inadequate and poorly equipped
health facilities, and poor communication capacity. As described in
the findings, data from health services are often incomplete, untimely,
and are not analysed and used to guide interventions. The multiple
reporting formats, non-uniform methods of reporting, unclear
guidelines, and lack of coordination pose an obstacle for effective
surveillance function which is a critical component in strengthening
the health system. As a result, epidemic detection, reporting,
forecasting, preparedness and response in South Sudan are
inadequate, and in most places almost non-existent.

Integration of disease surveillance refers to coordination of the
surveillance activities and supporting functions common to all control
programs (e.g., resources, training and supervision) recognizing the
need for specific follow up actions by the different specific intervention
programs to continue as planned. The core activities and supporting
functions in surveillance for most communicable diseases are similar
and therefore provide opportunities for integration and efficient use of
resources. The level of integration at the national surveillance system
can determine the performance, cost and sustainability of activities.
The challenge for South Sudan is to identify and exploit areas for
integration, while at the same time recognizing the special needs of
some programs for supplementary information or alternative methods
of surveillance. It is recognized that in some situations, surveillance
that is well developed in one program may act as a "driving force"
leading to improvement and strengthening of other surveillance
activities. The assessment of the surveillance system in South Sudan
indicates that the Polio surveillance, EWARN and Guinea worm
                                         37
               Southern Sudan Integrated Disease Surveillance & Response
eradication activities present opportunities for areas of integration for
surveillance of the selected priority diseases.

In recognition of the urgent need to forecast and contain outbreaks
through better program and resource planning, the MOH has adopted
the IDSR approach as an important component of the health services.
Integrated disease surveillance is expected to improve resource
mobilization and utilization, motivate health personnel, promote
partnership, and improve data compilation, flow, and timely use.



                                Objectives
3.1 General objective

Ensure better preparedness and response to epidemics with the aim of
reducing illnesses, disability and death from leading communicable
diseases.

3.2 Specific objectives

      Integrate communicable disease surveillance for priority
      diseases

      Improve capacity for integrated communicable disease
      surveillance at all levels with focus at Payam level

      Strengthen epidemic preparedness and response
      Establish trend analysis for major communicable diseases and
      targeted diseases for elimination and eradication


                                Strategies
Reviewing existing national surveillance activities: This provides
opportunities to identify gaps and potentials for enhancing IDSR; this
is carried out as part of the assessment and planning process.
Activities are identified based on the findings of this review;

      Establishing coordinating mechanisms: involves setting effective
      facilitating focal points at central, state, county and payam
      levels;
      Promoting IDSR partnership through advocacy: to implement
      IDSR effectively and smoothly, various stake holders-activities
      need to be synchronized for synergetic effect; To this end,
      partnership is critical;

                                         38
              Southern Sudan Integrated Disease Surveillance & Response
	

          Strengthening training of health personnel on IDSR: this is
          essential for various categories of health workers at different
          levels, including central, state, county and payam level staffs;

          Enhancing data management: involves building capacity for
          data collection, analysis and use for intervention on a timely
          and complete fashion;

          Facilitating	 communication:	      Building	    capacity	  for
          communication at all levels is critical for timely response in
          IDSR implementation;

          Building capacities of laboratories to support case confirmation:
          the gaps in	 this area are enormous requiring urgent
          intervention in improving the critical role of laboratory in IDSR;

          Strengthening epidemic prediction and response: this strategy
          involves using various activities	 that require institutional,
          human, financial and technical support.

          4.1 Targets for the Year 2007-2008

	1.	      Detection and registration:
          Standardized Case Definitions (SCDs) available in 80% of health
          facilities

    2.	   Case confirmation:
          Laboratory coordinators appointed at national and district levels
          Basic laboratory equipments and reagents available at national,
          state, and county and payam levels
          Minimum laboratory package defined for all levels
          Standard operating procedures (SOP) developed for all levels
          Ensure that the logistics for laboratory function including
          supervision and involvement in outbreak 	 investigation is
          available

    3.	   Reporting and feedback:
          Review of available forms and synchronization of data collection
          and reporting format completed
          Integrated reporting forms are available at 80% of health
          facilities
          A regular bulletin for surveillance is established at national level

    4.	   Data analysis and utilization:
          Data analysis modules available at 80% of districts

    5.	   Epidemic preparedness and response(EPR):
                                     39
                   Southern Sudan Integrated Disease Surveillance & Response
	

          Action thresholds available at all districts and in use by the end
          of the year
          National Epidemic response team established
          Functional rapid response teams set up in all states and EPR
          plans developed by the end of the year
          65% of Payams have Epidemic Preparedness and Response
          (EPR) kits

    6.	   Training, supervision and communication:
          Adaptation of WHO/AFRO technical guidelines completed
          Training needs assessment carried out at national level
          Training of trainers conducted at national and state level
          Supervisory checklist reviewed and disseminated to all districts
          Existing communication network constraints identified and
          rectified.

    7.	   Monitoring and evaluation
          All states and Payams(districts) have monitoring tools by the
          end of the year
          Internal evaluation carried out


                   Implementation Framework
    5.1 Role of the Ministry of Health

    Ministry of Health with support from its partners will be responsible
    for overall coordination and guidance for implementation of IDSR.
    This will be carried out during technical supervision and support to
    Directors of state and county Health Departments. This will be in
    addition to the establishment of standards and regulations affecting
    the program. The Director General of Preventive Health Services will
    ensure that adequate funds and resources are available for the
    national and state levels.

          The IDSR Unit /MOH will be responsible for the following:
          Coordination and follow up of the day to day activities of the
          unit
          Periodic review of health related data to determine the frequency
          and trends of occurrence of communicable diseases. This
          should be done in liaison with other stakeholders of disease
          surveillance.
          Provision to states, counties and payams the necessary
          technical support supervision for disease surveillance.
                                      40
                  Southern Sudan Integrated Disease Surveillance 86 Response
     Building of payam level capacity for disease surveillance by
     organizing training on disease surveillance.
     Provision of 'feed back on communicable diseases through
     preparation of quarterly surveillance reports.

5.2 Role of the State/County Health Department

The State/County health department is responsible for the planning,
management, monitoring and co-ordination of IDSR with all agencies
working within the state/county. Activities and required skills at
counties and Payams in the detection and response to priority
diseases are presented below:

5.2.1 Detection and Reporting
     Ensure that personnel know how to use Standard Case
     Definitions (SCD)
     In charge of health units know when and how to notify
     Review records of reported outbreaks
     Collect routine surveillance data timely
     Promptly notify next level
     Conduct special surveys as necessary

5.2.2 Data Analysis and Interpretation

      Define denominators
      Collect and aggregate data from health units
      Analyze data by person, place and time
      Calculate rates and establish thresholds
      Compare current data with previous data
      Prepare and regularly update graphs, tables, and charts
      Decide if action thresholds have been reached
      Make conclusions based on trends and analysed data
      Describe risk factors
      Report immediately and routinely to higher levels



                                        41
              Southern Sudan Integrated Disease Surveillance & Response
5.2.3 Investigation and Confirmation

     Arrange and lead investigation of reported cases or outbreaks
     Assist health facility in safe collection and transport of
     specimens for confirmation
     Receive and interpret laboratory results
     Decide if a reported outbreak is confirmed
     Report confirmed outbreak to next level
     Define laboratOry network in district and monitor laboratory
     quality and accessibility




                                        42
             Southern Sudan Integrated Disease Surveillance & Response
5.2.4 Response and Provision of Feedback

     Convene epidemic response committee
     Conduct training for emergency activities
     Select and implement appropriate public health response
     Prepare and update spot maps and line lists during response
     activity
     Plan timely community information and education
     Alert nearby areas and payams about confirmed outbreaks
     Provide feedback to health facilities
     Monitor routine prevention activities and modify them as
     needed


5.2.5 Evaluation and Actions taken

     Monitor timeliness and completeness of routine reports
     Monitor indicators of quality of surveillance for priority diseases
     Evaluate the effectiveness of and preparedness for response and
     recommend improvements
     Take action to improve on-going case management and
     prevention activities for priority diseases or conditions

                Monitoring and Evaluation
Annual internal and bi-annual external evaluations will be conducted
to monitor the implementation of the plan of action. Progress will be
measured against the targets. Re-direction of the implementation, if
necessary will be done after the evaluations.




                                        43
             Southern Sudan Integrated Disease Surveillance 86 Response
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                                                 54
                      Southern Sudan Integrated Disease Surveillance & Response
                   Southern Sudan IDSR Plan of Action

LOGFRAME FOR 2007-08 PLAN OF ACTION FOR IDSR IMPLEMENTATION IN
                        SOUTHern SUDAN
SUMMARY:


Areas /Functions                                                    Amount in USD

  DETECTION and REGISTRATION                                        $	      38,000.00
  LABORATORY CASE CONFIRMATION                                      $	   267,000.00
  REPORTING AND FEEDBACK.                                           $	   170,000.00
  DATA ANALYSIS AND UTILIZATION
  EPIDEMIC PREPAREDNESS AND RESPONSE (EPR).                         $	   240,000.00
  TRAINING, SUPERVISION AND COMMUNICATION.                          $	   980,000.00
7. MONITORING AND EVALUATION.                                                 30,000

Grand TOTAL (US Dollars)                                            $ 1,725,000.00




                                             55
                   Southern Sudan Integrated Disease Surveillance Respons

				
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